JACM : Treatment of Covid-19

Meditation and Yoga Practices as Potential Adjunctive Treatment of SARS-CoV-2 Infection and COVID-19: A Brief Overview of Key Subjects

• William Bushell
, , PhD
• Ryan Castle
, , BS
• Michelle A. Williams
, , ScD
• Kimberly C. Brouwer
, , PhD
• Rudolph E. Tanzi
, , PhD
• Deepak Chopra
, , and MD
• Paul J. Mills
, PhD

Editor's Note: As an acute condition quickly associated with multiple chronic susceptibilities, COVID-19 has rekindled interest in, and controversy about, the potential role of the host in disease processes. While hundreds of millions of research dollars have been funneled into drug and vaccine solutions that target the external agent, integrative practitioners tuned to enhancing immunity faced a familiar mostly unfunded task. First, go to school on the virus. Then draw from the global array of natural therapies and practices with host-enhancing or anti-viral capabilities to suggest integrative treatment strategies. The near null-set of conventional treatment options propels this investigation. In this paper, researchers from the Massachusetts Institute of Technology, University of California-San Diego, Chopra Library for Integrative Studies, and Harvard University share one such exploration. Their conclusion, that “certain meditation, yoga asana (postures), and pranayama (breathing) practices may possibly be effective adjunctive means of treating and/or preventing SARS-CoV-2 infection” underscores the importance of this rekindling. At JACM, we are pleased to have the opportunity to publish this work. We hope that it might help diminish in medicine and health the polarization that, like so much in the broader culture, seems to be an obstacle to healing. —John Weeks, Editor-in-Chief, JACM

Potential Adjunctive Therapies for SARS-CoV-2 Infection and COVID-19 Disease

There is an urgent need to identify strategies to help prevent and treat SARS-CoV-2 infection and COVID-19 disease.1–4 Included among the intensive search for novel and effective therapeutic approaches are considerations of those therapies derived from integrative and complementary medicine,5–8 including from traditional whole medicine systems such as Chinese Medicine and Ayurvedic medicine.6–8 In this article, the authors present a selective narrative review of the literature with a primary focus on certain complementary practices of seated meditation, yoga asanas (postures), and pranayama (breathing) with relevance to immune function for consideration for SARS-CoV-2 infection and COVID19 treatment and/or prevention.

The authors propose that certain complementary practices may be helpful adjunctive means of treating and/or preventing SARS-CoV-2 infection1,9 and helping to reduce severity of COVID-19 disease, including its collateral effects and sequelae. Despite being speculative for the present situation, there is a body of literature relevant to the antistress and anti-inflammatory effects of certain seated meditation, yoga asanas, and pranayama practices. Such studies include demonstrating promising immune effects relevant to improving lung health10,11 and reducing viral susceptibility and improving acute respiratory infections.12–14 The potential benefits of these practices extend to broader neuroimmune systems, an advantage when dealing with a systemically dysregulating disease such as SARS-CoV-2.15 Such complementary practices have been found to act as a regulating influence on a number of key inflammatory functions that SARS-CoV-2 disrupts.16

The use of certain complementary practices as potentially effective adjunctive means of treating and/or preventing SARS-CoV-2 infection must be put to rigorous scientific investigation. During this time, however, when there are numerous exploratory pathways being urgently probed,1,2,6,8 it is important to look to “evidence-based principles that emphasize the practical application of the findings of the best available current research” (see “implementation of evidence-based interventions” defined and advocated by NIH/CDC).17 With this consideration in mind, best available research reasonably advocates that the utilization of certain forms of some complementary practices be examined as potential adjunctive interventions to help prevent and treat SARS-CoV-2 infection and potential future pandemics.

Theoretical frameworks as models have been put forth seeking to explain how complementary practices such as seated meditation, yoga asanas, and pranayama work, which have examined multiple psychologic, emotional, epigenetic, neural, and behavioral processes, as well as shifts in self-awareness.18–24 An in-depth model proposed by Holzel et al., for example, focuses on mindfulness meditation practice-induced changes in attention regulation, body awareness, emotion regulation, and perspective of self, citing supportive underlying neuroplastic changes.18 Gard et al. examine the effects of yoga practices on cognition, emotional, and behavioral regulation, and autonomic output under stress with an emphasis on interoceptive processes and self-regulation.19

The current state of the rapidly evolving field of Integrative Medicine research intersects with the intensive search for successful treatments for this pandemic viral infection. When considering complementary practices, the National Academy of Science's Institute of Medicine stated that the field of “behavioral medicine” should be considered in the evolving standard model of fundamental life science research and should be advocated on the front line of serious medical and health-optimizing treatment and intervention.25 With this in mind, in 2009, one of the authors (W.B.), with the collaboration of Neil Theise MD (then of the Albert Einstein College of Medicine), began to review the scattered and disparately emerging body of research on the inflammatory cytokine-based pathogenesis of many virulent infectious diseases (bacterial, viral, other) and “cytokine storms,”26 following the pioneering work of Clark et al.27 and others. This was connected with research into the potential anti-inflammatory, antistress, and anti-infectious properties of meditation and yoga practices, thereby beginning the development of a scientific model in behavioral health.26,28 This developing scholarly territory needs to be fully explored with scientific rigor and open minds due to both its inherent value and the urgency of the present situation.29,30

Anti-Inflammatory Effects Associated with Meditation and Yoga Practices

An extended runaway hyperinflammatory host response to SARS-CoV-2 infection is the primary pathway to COVID-19 disease morbidity and mortality.31 Spread of the virus through the body leads to widespread and intensive activation of the inflammatory defenses, although originally intended to combat the pathogen, but instead resulting in widespread tissue damage to the host, to acute respiratory distress syndrome (ARDS); the virus itself plays a much lesser role in the tissue damage that can ultimately produce extreme critical disease states (pulmonary aspiration, septic shock), and potentially death.15,32

Beginning in the mid-1990s and developing up to the present, increases in scientific knowledge about the immune system and the inflammatory dimension of it led to the recognition that many infectious diseases caused their damage to a large extent through the host's own inflammatory responses.27 Around the same time, research by Kevin Tracey and colleagues33 (and see Bushell, Olivo, Theise, 2009)34 led to the discovery that inflammation could be brought under control through stimulation of the vagal nerve complex, a major component of the central and peripheral nervous system, which also controls responses to psychosocial stress, and stimulation of which can reverse the “fight or flight” response through replacing it with the “relaxation response,”35 in simplified schematic terms.

Starting in the early 2000s, Bushell and colleagues proposed that intensive forms of meditation and yoga could potentially be effective as adjunctive interventions against serious forms of infectious diseases, including malaria, HIV/AIDS, and SARS, among others. These authors were at the time demonstrating an appreciation of the key significance of the common denominator of the inflammatory-driven pathogenesis of the spectrum of such virulent infectious diseases and the potentially important relevance of the antistress and anti-inflammatory properties of these behavioral health practices for possible forms of adjunctive preventative or treatment therapies.27,36–38

It had also been found that meditation, as well as yoga practices, is capable of significantly increasing vagal tone and therefore could not only be effective against psychologic stress-based issues, including trauma,39,40 but inflammatory-based diseases as well.16,41–46 Included in this consideration are studies documenting effects of a diverse range of meditative and yoga practices to promote anti-inflammatory and typically reduce proinflammatory cytokine activity, incuding natural killer (NK) cell activity and NK and T cell cytokine production,45–50 which has been a topic of two systematic reviews.51,52 For example, Bower et al.49 showed that 6 weeks of 20-min daily mindfulness meditation resulted in a significant downregulation of a 19-transcript composite of proinflammatory genes and a significant reduction of activity of the proinflammatory transcription factor nuclear factor kappa B (NF-κB). In parallel, they observed an increase of anti-inflammatory glucocorticoid receptor activity and increased type I interferon signaling, a transcription factor linked to SARS-CoV-2 treatment.

Other studies show decreases in the circulating levels of the proinflammatory cytokine interleukin (IL)-12 and increases of the anti-inflammatory cytokine IL-10.47,48,50 In specific patient groups or obese individuals, other studies document reductions in circulating levels of C-reactive protein (CRP) and IL-6,49,50,53 although these findings were not replicated by some investigators.48 Some of the cytokine-related effects of seated meditation, breathing practices, and yoga asana practices are related to a reduction in sympathetic nervous system activation, as evidenced by parallel reductions in levels of the catecholamines epinephrine and norepinephrine.47,52,54 Studies also suggest differential effects of meditation practices on immune cell subsets, including NK and T cells, of relevance to the innate and adaptive immune systems.55,56

The benefits of yoga therapies on the health of the innate immune system have also been demonstrated in a study showing that 90 min of yogic asana stretching is able to increase expression of the two important antimicrobial peptides, β-defensin and HBD-2 expression.57 Importantly, with regard to COVID-19, both of these antimicrobial peptides are expressed in respiratory epithelial cells.58 Yoga therapy has also been shown to downregulate the cytokine receptors tumor necrosis factor (TNF)-RII and IL-1RA, and stress-related CRP.59 Epel et al. showed that combined mantra-based meditation and yoga asana practices regulated levels of the proinflammatory cytokine TNF-α and metabolism of the Alzheimer's disease-associated amyloid-β protein,60 and also reported reduced expression of proinflammatory genes in association with a meditation practice.